Cardiovascular disease is the leading cause of death among veterans enrolled in the Veterans Health Administration (VHA), and it is also a major component of the VHA's operating costs. In recent years, VHA has undertaken numerous quality-of-care initiatives to improve health outcomes in patients with heart disease. Simultaneously, fiscal pressures on VA's clinical operations have increased, and the VHA's is increasingly compelled to optimize the value of its health care (i.e., improve outcomes while conserving limited resources). While VHA continuously collects and reports numerous process-of-care quality measures to assess clinical performance across VA medical centers (VAMCs), there is much less known about cardiovascular outcomes and costs of care at the VAMC level. This absence of information prevents VHA leadership from having a clear picture of the comparative performance of VAMCs in providing high-quality cardiovascular care that maximizes value. Our multi-disciplinary team of highly experienced investigators in cardiovascular outcomes and economics proposes to compare the outcomes and costs of care for two widely prevalent and high-cost cardiovascular conditions-ischemic heart disease (IHD) and chronic heart failure (CHF)-across the VA's 150 VAMCs from fiscal year 2010 to 2014. The specific aims of the research project are: (1) to identify the VAMCs that consistently produced excellent risk-adjusted health outcomes for veterans with IHD and CHF during this five-year period and quantify the costs of care associated with producing these outcomes; (2) to identify and quantify the structural aspects of CHF/IHD care at these VAMCs that are most conducive to optimal outcomes and economic efficiency, with a particular focus on the influence of the local frequency of several high-cost components of care, including: cardiovascular imaging, implantable device utilization, off-station major cardiovascular care, and non-elective hospitalizations; and (3) to explore in depth the key clinical, programmatic, and leadership, and factors that produced these outcomes via interviews with the leadership and clinical providers at that nation's top-performing and low-performing VAMCs. To address these research aims, we will combine data from the VA's National Patient Care Databases, the VA's Decision Support System National Data Extract databases, and the VA's Fee Basis Care Database-all housed at the VA's Corporate Data Warehouse. Additional data will be obtained from the American Hospital Association's Annual Hospital Survey and from the VA/Centers for Medicare and Medicaid Services data available from the VA Information Resource Center. Multivariable statistical analyses using hierarchical generalized linear models will be conducted to investigate hospital-level outcomes and costs of cardiovascular care while controlling for key differences across VAMCs in their CHF and IHD patient populations. We will follow this quantitative analysis with a qualitative assessment of information collected in a series of telephone-based interviews with administrative and clinical leadership as well as front-line clinicians at the top 5 VAMCs and bottom 5 VAMCs in terms of cardiovascular care value. This grounded theory qualitative analysis will identify the key institutional, programmatic, and leadership factors that characteriz the nation's top-performing VA Medical Centers (VAMCs) in high-value IHD and CHF care, providing a critical blueprint to VA clinical and operations leaders seeking to improve cardiovascular care throughout the VA's health system. Our results subsequently will be communicated to key policy and clinical leaders in VA cardiology via the provider networks maintained by the VA's Chronic Heart Failure and Ischemic Heart Disease Quality Enhancement Research Initiatives (QUERIs), whose leaders will partner with the project's research team as co-investigators in the design and conduct of the study, as well as the dissemination of the research results.